Disparities in colorectal cancer screening revealed among European nations

In a recent study published in The Lancet Regional Health Europe, researchers investigated the use of fecal testing and colonoscopies for colorectal cancer (CRC) screening.

They also examined factors influencing their use based on unique screening program characteristics in European countries.

Study: Utilization of colorectal cancer screening tests across European countries: a cross-sectional analysis of the European health interview survey 2018–2020. Image Credit: Jo Panuwat D/Shutterstock.comStudy: Utilization of colorectal cancer screening tests across European countries: a cross-sectional analysis of the European health interview survey 2018–2020. Image Credit: Jo Panuwat D/Shutterstock.com


CRC screening tests in European nations over the past 20 years have lowered incidence and death rates. Previous research conducted by the current study's researchers revealed that the fraction of the general public updated on these screening procedures varied greatly among European nations, ranging between 6.0% and 71%.

Younger individuals who hadn't visited health professionals in a while and were at higher risk owing to lifestyle variables showed a lower likelihood of undergoing screening tests.

With an expansion in population-level colorectal cancer screening programs across Europe, it is critical to review screening data from recent years to determine screening test usage.

About the study

In the present study, researchers evaluated colonoscopy and fecal test use based on data from the third EHIS wave and investigated characteristics related to utilization in European nations.

The researchers analyzed the 2018-2020 EHIS data to assess the use of a fecal test [fecal immunochemical test (FIT) or guaiac-based fecal occult blood test (gFOBT)] in the previous two years or a colonoscopy in the prior ten years among individuals aged 50 to 74 years, depending on the screening test type in every country. 
After removing respondents from France, whose microdata were unavailable for our study, proxy interviews, and respondents outside the appropriate age range, the study included 129,750 participants.

After deleting missing data and age categories not included in screening programs, 117,095, 124,326, and 122,707 respondents were analyzed using the Andersen behavioral model to determine the use of fecal tests, colonoscopies, and either test.

The EHIS modules collected data on socioeconomic, demographic, healthcare usage, and health-related characteristics. The healthy lifestyle score (HLS) was calculated based on smoking behaviors, physical activity, body mass index (BMI), and alcohol use.

The study used multivariate logistic regressions to determine the odds ratios (OR) for analysis. 

The EHIS-3 data collection divided countries based on fecal test utilization as those with fully implemented nationwide fecal test programs, partially implemented programs, opportunistic programs that offer fecal testing, and only small-scale pilot programs or no fecal test programs.

They classified colonoscopy use in Europe into four categories: countries having fully implemented programs using fecal tests, partially implemented programs, countries offering colonoscopies as an alternative CRC screening modality, countries with no program, small-scale organized programs, or opportunistic programs with fecal tests.


The researchers analyzed data about 129,750 individuals residing in 29 European nations, including 1,511 Icelanders and 11,755 Germans. Unit responses varied between 22% and 88%.

Either test use was highest in nations having completely rolled-out fecal test programs [between 38% (867 out of 2,379) in Croatia and 75% (2,321 out of 3,085) in Denmark] as well as among nations offering colonoscopy rather than conventional screening [between 26% (854 out of 3,329) in Greece and 75% (1,192 out of 1,760) in Luxembourg].

The researchers found that nations with no or limited-scale screening programs had the lowest utilization of either test (6.3% in Bulgaria and 34% in Latvia). Younger individuals aged 50 to 59 years without partners showed lower odds of undergoing CRC screening than elders.

Individuals without secondary education were 21%-40% less likely to use either test than those educated till tertiary level  (ORs 0.6–0.8). Households with at least three individuals showed lower odds of CRC screening (ORs ranged between 0.8 in nations with completely rolled-out screening programs and 0.9 in those having partially rolled-out programs).

Furthermore, lower HLS values (less healthy lifestyles) were related to less screening. Individuals who had not seen a doctor for 12 months showed a significantly lower likelihood of taking CRC tests (ORs 0.5 to 0.6).

Rural residents showed decreased colonoscopy usage (ORs 0.8 to 0.9) than their urban counterparts, but those who assessed their health as below good showed a higher likelihood of undergoing colonoscopy (ORs 1.2 to 1.3).


The study found discrepancies in fecal testing and colonoscopy use in average-risk Europeans aged 50 to 74 years. Despite advances in colorectal cancer screening, a few European countries have updated eligible populations on screening tests.

Organized screening programs using fecal testing have the highest usage, although with significant variations. The study underscores the need to solve the screening paradox, in which individuals with unhealthy lifestyle habits and the highest colorectal cancer risk underutilize screening.

Countries with partially implemented programs have lower use rates due to demographic differences. Countries that provide fecal testing and colonoscopies have observed rising demand, notably for colonoscopies.

Journal reference:
Pooja Toshniwal Paharia

Written by

Pooja Toshniwal Paharia

Pooja Toshniwal Paharia is an oral and maxillofacial physician and radiologist based in Pune, India. Her academic background is in Oral Medicine and Radiology. She has extensive experience in research and evidence-based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.


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